If yes, please list name and severity of your allergy and any medication required

Name of Drug

Type of Food

Describe Reaction

Tetanus Immunisation

It is particularly important that people dealing with horses are immunised against tetanus. Tetanus is normally given at five years of age as Triple antigen or CDT and at fifteen years of age as ADT. Year of last tetanus immunisation

Medication

Is it necessary for your child to carry their own medication at all times?

Consent To Medical Attention

I authorize the instructor in charge to administer first aid and call an ambulance if necessary for the medical attention of my child. I agree to bear any cost thereby incurred *

Yes

No

Ambulance Cover

Covered

Yes

No

Membership Number

Expiry

Private Health Insurance

Name of Company

Type of Cover

Contact Details

Contact Name

Contact Phone

Contact Email

Subject

Message

1. Please tick the appropriate box if your child suffers from the following:

Bed Wedding

Sleepwalking

Soiling

Seizures

Diabetes

Headaches

Vision Impairment

Hearing Loss

Dizzy Spells

Heart Condition

Blackouts

Hay fever

Asthma

Fears/Phobias

Other

If Yes, please give details:

2. Does your child have any chronic illness, medical condition, or physical restriction? YES / NO

3. Please tick the box which best describes your child’s ability to swim:

Excellent

Good

Poor

Non Swimmer

Further Comments:

4. Is this your child’s first trip away from home without you?

YES

NO

5. Please tick the appropriate box if you child has been diagnosed with any of the following:

Autism

Tourette ’s syndrome

ADHD

Intellectual Disability

Physical Disability

ODD

Mental Health Condition

Aspergers Syndrome

Other

If Yes, please provide a Behaviour Management Plan and further details:

6. Please tick the appropriate box if your child needs assistance with any of the following:

Bedtime

Toileting

Hygiene

Meal Times

Showering

Other

If Yes, please give details:

10. All prescribed medication is the be provided in a pharmacy issues Blister Pack, Webster Pack, or Dossette Box, that is clearly labeled. If your child is on medication, please list below:

Medication Name

Dosage - Before B/Fast

Dosage - B/Fast

Dosage - Other times

Dosage - Lunch

Dosage - Other times

Dosage - Dinner

Dosage - Other times

Dosage - Bedtime

Further Comments and Side Effects:

PARENT'S/GUARDIAN'S STATEMENT

PARENT'S/ GUARDIAN'S SIGNATURE

DATE

Wallington Park

We cater for all levels of riders in all Olympic disciplines. Our agistees have use of top facilities, including indoor and outdoor arenas, cross country course and showjumping.